1[FORM 1(A)
[To be completed by the prospective related donor]
[Refer rule 3]

My full name is .............................................And this is my photograph

My permanent home address is
......................................................................................................
.................................................................Tel:.................................

My present home address is ......................................................................................................
..................................................................Tel:................................

Date of birth............................(day/month/year)
• Ration/consumer Card number and Date of issue & place .......................(Photocopy attached) and/or
• Voter’s I-Card number, date of issue, Assembly Constituency ..................................... (Photocopy attached) and/or
• Passport number and country of issue .............................................(Photocopy attached) and/or
• Driving Licence number, Date of issue, licensing authority ........................................... and/or
• PAN.............................................................. and/or
• Other proof of identity and address..........................................................
I hereby authorize removal for therapeutic purposes/consent to donate my ................ (state which organ) to my relative (specify son / daughter / father / mother / brother / sister), whose name is ........... ..........................and who was born on ..........................
(day / month / year) and whose particulars are as follows: To be affixed and attested by Notary Public after it is affixed. • Ration/consumer Card number and Date of issue & place .......................(Photocopy attached) and/or
• Voter’s I-Card number, date of issue, Assembly Constituency ..................................... (Photocopy attached) and/or
• Passport number and country of issue .............................................(Photocopy attached) and/or
• Driving Licence number, Date of issue, licensing authority ........................................... and/or
• PAN.............................................................. and/or
• Other proof of identity and address ...........................................

I solemnly affirm and declare that:-
Sections 2, 9, and 19 of the transplantation of Human Organs Act, 1994 have been explained to me and I confirm that: -

1. I understand the nature of criminal offences referred to in the sections.
2. No payment of money or money’s worth as referred to in the sections of the Act has been made to me or will be made to me or any other person.
3. I am giving the consent and authorisation to remove my ........................... (organ) of my own free will without any undue pressure, inducement, influence or allurement.
4. I have been given a full explanation of the nature of the medical procedure involved and the risks involved for me in the removal of my...................................(organ). That explanation was given by ........................... (name of registered medical practitioner).
5. I understand the nature of that medical procedure and of the risks to me as explained by that practitioner.
6. I understand that I may withdraw my consent to the removal of that organ at any time before the operation takes place.
7. I state that particulars filled by me in the form are true and correct to my knowledge and nothing material has been concealed by me.

.......................................... Signature of the prospective donor

............... Date

Note : To be sworn before Notary Public, who while attesting shall ensure that the person / persons swearing the affidavit(s) signs (s) on the Notary Register, as well.
• √Wherever applicable.

FORM 1(B)
[To be completed by the prospective spousal donor]
[Refer rule 3]

My full name is .............................................And this is my photograph My permanent home address is ...................................................................................................... .................................................................Tel:.................................
My present home address is ...................................................................................................... ..................................................................Tel:................................
Date of birth............................(day/month/year)
I authorize to remove for therapeutic purposes / consent to donate my...............(state which organ) to my husband/wife ........................ Whose full name is ....................... Who was born on..............................(day / month / year) and whose particulars are as follows:
• Ration/consumer Card number and Date of issue & place .......................(Photocopy attached) and/or
• Voter’s I-Card number, date of issue, Assembly Constituency ..................................... (Photocopy attached) and/or
• Passport number and country of issue .............................................(Photocopy attached) and/or
• Driving Licence number, Date of issue, licensing authority ........................................... and/or
• PAN.............................................................. and/or
• Other proof of identity and address ...........................................

I submit the following as evidence of being married to the recipient:-

1. A Certified copy of a marriage certificate or
2. An affidavit of a “near relative” confirming the status of marriage to be sworn before Class-I Magistrate / Notary Public.
3. Family photographs.
4. Letter from member of Gram Panchayat / Tehsildar / Block Development Officer / MLA / MP certifying factum and status of marriage.
or
5. Other credible evidence

I solemnly affirm and declare that:-
Sections 2, 9, and 19 of the transplantation of Human Organs Act, 1994 have been explained to me and I confirm that: -

1. I understand the nature of criminal offences referred to in the sections.
2. No payment of money or money’s worth as referred to in the sections of the Act has been made to me or will be made to me or any other person.
3. I am giving the consent and authorisation to remove my ........................... (organ) of my own free will without any undue pressure, inducement, influence or allurement.
4. I have been given a full explanation of the nature of the medical procedure involved and the risks involved for me in the removal of my...................................(organ). That explanation was given by ........................... (name of registered medical practitioner).
5. I understand the nature of that medical procedure and of the risks to me as explained by that practitioner.
6. I understand that I may withdraw my consent to the removal of that organ at any time before the operation takes place.
7. I state that particulars filled by me in the form are true and correct to my knowledge and nothing material has been concealed by me.

.......................................... Signature of the prospective donor

............... Date

Note : To be sworn before Notary Public, who while attesting shall ensure that the person / persons swearing the affidavit(s) signs (s) on the Notary Register, as well.
• √Wherever applicable.

FORM 1(C)
[To be completed by the prospective unrelated donor].
(Refer rule 3)

My full name is .............................................And this is my photograph
My permanent home address is ...................................................................................................... .................................................................Tel:.................................
My present home address is ...................................................................................................... ..................................................................Tel:................................
Date of birth............................(day/month/year)
• Ration/consumer Card number and Date of issue & place .......................(Photocopy attached) and/or
• Voter’s I-Card number, date of issue, Assembly Constituency ..................................... (Photocopy attached) and/or
• Passport number and country of issue .............................................(Photocopy attached) and/or
• Driving Licence number, Date of issue, licensing authority ........................................... (Photocopy attached) and/or
• PAN.............................................................. and/or
• Other proof of identity and address ...................................
• Details of last three years income and vocation of donor.......................................
I hereby authorize to remove for therapeutic purposes/consent to donate my ................ (state which organ) to a person whose full name is ........... ..........................and who was born on .......................... (day / month / year) and whose particulars are as follows:
• Ration/consumer Card number and Date of issue & place .......................(Photocopy attached) and/or
• Voter’s I-Card number, date of issue, Assembly Constituency ..................................... (Photocopy attached) and/or
• Passport number and country of issue .............................................(Photocopy attached) and/or
• Driving Licence number, Date of issue, licensing authority ........................................ (Photocopy attached) and/or
• PAN.............................................................. and/or
• Other proof of identity and address ...........................................

I solemnly affirm and declare that:-
Sections 2, 9, and 19 of the transplantation of Human Organs Act, 1994 have been explained to me and I confirm that: -

1. I understand the nature of criminal offences referred to in the sections.
2. No payment of money or money’s worth as referred to in the sections of the Act has been made to me or will be made to me or any other person.
3. I am giving the consent and authorisation to remove my ........................... (organ) of my own free will without any undue pressure, inducement, influence or allurement.
4. I have been given a full explanation of the nature of the medical procedure involved and the risks involved for me in the removal of my...................................(organ). That explanation was given by ........................... (name of registered medical practitioner).
5. I understand the nature of that medical procedure and of the risks to me as explained by that practitioner.
6. I understand that I may withdraw my consent to the removal of that organ at any time before the operation takes place.
7. I state that particulars filled by me in the form are true and correct to my knowledge and nothing material has been concealed by me.

.......................................... Signature of the prospective donor

............... Date

Note : To be sworn before Notary Public, who while attesting shall ensure that the person / persons swearing the affidavit(s) signs (s) on the Notary Register, as well.
• √Wherever applicable.

1[FORM 2]
[To be completed by the concerned medical practitioner]
[Refer rule 4(1) (b)]

I, Dr. ...............possessing qualification of ................... registered as medical practitioner at Serial No. ............... by the ................Medical Council, certify that I have examined Shri/Smt./ Km ............... s/o, w/o, d/o Shir ..................aged ...............who has given in-formed consent about donation of the organ, namely (name of the organ ................ to Shri/Smit./Km ....................... who is a “near relative” of the donor / other that near relative of the donor, who had been approved by the Authorisation Committee / Registered Medical Practitioner i.e. In-charge of transplant center (as the case may be) and that the said donor is in proper state of health and is medically fit to be subjected to the procedure of organ removal.

Place ......................... Date ..........................

................................ Signature of Doctor seal

1[FORM 3
[Refer rule 4(1) (c)]

I, Dr./Mr./Mrs.. ..…………………….working as ………………………at …………………………… and possessing qualification of ……………………..certify that Shri / Smt. Km. ………………………………………. S / o, D / o, Wo Shri / Smt. ………………………………………. aged ……………….. the donor and Shri / Smt. ………………………. S / o, D /o, W/o, Shri / Smt ……………….. aged ……………… the proposed recipient of the organ to be donated by the said donor are related to each other as brother / sister / mother /father /sons /daughter as per their statement and the fact of this relationship has been established / not established by the results of the tests for Antigenic Products of the Human Major Histocompatibility Complex. The results of the test are attached

Place ......................... Date ..........................

................................ Signature (To be signed by the Head of the Laboratory)

FORM 4

[Refer Rule 4 (1) (d)]

I, Dr. ............ possessing qualification of .................. registered as medical practitioner at Serial No .............. by the ............. Medical Council, certify that :-

(i) Shri..........................s/o Shri..............................aged ...................... .. resident of............................and Smt ....................D / o, w / o Shri .................. aged.............. .............resident of........................Are related to each other as spouse according to the statement given by them and their statement has been confirmed by means of following evidence before effecting the organ removal from the body of the said Shri/ Smt. / Km ...............………………….(Applicable only in thecases where considered necessary).

OR

(ii) The clinical condition of Shri / Smt ..................... mentioned above is such that recording of his /her statement is not practicable.

Place................. Date.................

Signature of Registered Medical Practitioner.....................

FORM 5
[Refer rule 4(2) (a)]

I, ..........s / o, d / o, w / o Shri ............. aged .............. resident of ........... in the presence of mentioned below hereby unequivocally authorize the removal of my organ / organs, namely, .............. from my body after my death for therapeutic purposes.

Date......................... (Signature)..........................

.......................................... Signature of the Donor

1. Shri / Smt. / Km. ............... s /o, w / o, d / o Shri ....................... aged ...................... resident of...................................


(Signature)


2. Shri / Smt. / Km. ...........s /o, w / o, d / o Shri............. aged ................ resident of .............. is a near relative to the donor as ..............


Date...............................

FORM - 6
[(See rule 4(2) (b)]

I................................... s/o,d/o,w/o .......................
aged ...................resident of. .............................. having lawful possession of the dead body Sri/Smt/km .....................s/o,d/o,w/o ..................................
aged........... resident of..................................................... having known that the deceased has not expressed any objection to his/her organ/organs being removed for therapeutic purposes after his/her death and also having reasons to believe that no near relative of the said deceased person has objection to any of his/her organs being used for therapeutic purposes authorise removal of his/her body organs.

Signature.....................
name. .......................
Dated..........................
Place.................
Person in lawful possession of the dead body
Address..................................................................
..............................................................................

FORM 8

[Refer rule 4(3) (a) and (b)]

We, the following members of the Board of Medical Experts after careful personal examination, hereby certify that Shri/ Smt. / Km ........................... aged about ................... ....…………. s / o, w /o, d / o, Shri .............................. resident of ............................... is dead on ac- count of permanent and irreversible cessation of all functions of the brain-stem. The tests carried out by us and the findings therein are recorded in the brain-stem death certificate annexed hereto.

Date.........................................

Signature.........................................

1. R.M.P., Incharge of the Hospital in which brain-stem death has occurred.
2. R.M.P., nominated from the panel of names approved by the Appropriate Authority.
3. Neurologist / Neuro-Surgeon nominated from the panel of names approved by the Appropriate Authority.
4. R.M.P., treating the aforesaid deceased person.

BRAIN-STEM DEATH CERTIFICATE

(A) Patient Details: 3. Hospital Number ................................................................
4. Name and address of next of kin or person .............................
responsible for the patient (if none exists, this ..................................................... must be specified)
..................................
5. Has the patient or next of kin agreed to any transplant? ............................
6. Is this a Police Case?                                         Yes...................... No......................


(B) Pre-Conditions: 1. Diagnosis: Did the patient suffer from any illness or accident that led to irreversible brain damage? Specify details: ......................... ..........................................................................................
Date and time of accident/onset of illness .................................
Date and onset of non-responsible coma ...................................
2. Findings of Board of Medical Experts:
(1) The following reversible cause of coma have been excluded:-
Intoxication (Alcohol)
Depressant Drugs
Relaxants (Neuromuscular blocking agents)
       

First Medical Examination             Second Medical Examination

Primary hypothermia
Hypovolaemic shock
Metabolic of endocrine disorders
Test for absence of brain-stem functions
(2) Coma
(3) Cessation of spontaneous breathing
(4) Pupillary size
(5) Pupillary light reflexes
(6) Doll’s head eye movements
(7) Corneal reflexes (Both sizes)
(8) Motor response in any cranial nerve distribution, any responses to stimulation of face, limb or trunk
(9) Gag reflex
(10) Cough (Tracheal)
(11) Eye movements on coloric testing bilaterally
(12) Apnoea tests as specified
(13) Were any respiratory movements seen ?
...........................................................................................
Date and time of first testing: .................................................
Date and time of second testing: ............................................
This is to certify that the patient has been carefully examined twice after an interval of about six hours and on the basis of findings recorded above,
Shri / Smt / Km................................................. is declared brain-steam dead.
1. Medical Administrator Incharge of the hospital.
2. Authorised Specialist.
3. Neurologist / Neuro-Surgeon.
4. Medical Officer treating the patient.
N.B
       I. The Minimum time interval between the first testing and second
Testing will be six hours.
       II. No. 2 and No. 3 will be co-opted by the Administrator Incharge of the hospital from the panel of experts approved by the Appropriate Authority.

FORM 9

[Refer rule 4(3) (a) (b)]

I, Shri/Smt. .............. s / o. w / o, Shri ................ resident of ........... hereby authorize removal of the organ / organs, namely, ......... for therapeutic purpose from the dead body of my son / daughter Shri / Km. ...........aged ............. Whose brain-stem death has been duly certified in accordance with the law.

Signature........................................
Name.................

Date................
Place....................

1[FORM 10
APPLICATION FOR APPROVAL FOR TRANSPLANTATION (LIVE DONOR)
[To be completed by the proposed recipient and the proposed donor]
[Refer Rule 4(1) (a) (b)]

   Whereas I ................................................ S / o, D / o, W /o, Shri/Smt. ......................................... aged ................................. residing at ......................................................................... have been advised by my doctor ................................... that I am suffering form ..................................................... and may be benefited by transplantation of........................................................ into my body.
   And Whereas I .........................................S / o, D / o, W / o, Shri / Smt. ................................................. aged ........................................... residing at ....................................................... by the following reason (s): -
(a) by virtue of being a near relative i.e. …………………….
(b) by reason of affection / attachment / other special reason as explained below:- ........................................................................................ ...............................................................................................
 I would therefore like to donate my (name of the organ) ........................to Shri / Smt. .................................................. We ..........................................and ..............................................
                                                                       (Donor)                                            (Recipient)
   hereby apply to Authorisation Committee for permission for such transplantation to be carried out.
We solemnly affirm that the above decision has been taken without any undue pressure, inducement, influence or allurement and that all possible consequences and options of organ transplantation have been explained to us.

Instructions for the applications:-
1. Form 10 must be submitted along with the completed Form 1(A), or Form 1(B) or Form 1 (C) as may be applicable.
2. The applicable Form i.e. From1(A) or Form 1(B) or Form 1(C), as the case may be, should be accompanied with all documents mentioned in the applicable form and all relevant queries set out in the applicable form must be adequately answered.
3. Completed Form 3 to be submitted along with the laboratory report.
4. The doctor’s advice recommending transplantation must be enclosed with the application.
5. In addition to above, in case the proposed transplant is between unrelated persons, appropriate evidence of vocation and income of the donor as well as the recipient for the last three years must be enclosed with this application. It is clarified that the evidence of income does not necessarily mean the proof of income-tax returns, keeping in view that the applicant(s) in a given case may not be filing income-tax returns.
6. The application shall be accepted for consideration by the Authorisation Committee only if it is complete in all respects and any omission of the documents or the information required in the forms mentioned above, shall render the application incomplete.
7. As per the Supreme Court’s judgement dt. 31-3-2005, the approval/No Objection Certificate from the concerned State / Union Territory Government or Authorisation Committees is mandatory from the domicile State / Union Territory of donor as well as recipient. It is understood that final approval for transplantation should be granted by the Authorisation Committee / Registered Medical Practitioner i.e. Incharge of transplant center (as the case may be) where transplantation should be done.

We have read and understood the above instructions.

Signature of the Prospective Donor

Signature of the Prospective Recipient

Date ..................

Date ..................

Place ..................

Place ..................

FORM 11
APPLICATION FOR REGISTRATION OF HOSPITAL TO CARRY OUT ORGAN TRANSPLANTATION

To
   The Appropriate Authority for organ transplantation ........................ (State or Union Territory)
   We hereby apply to be recognized as an institution to carry out organ transplantation. The required data about the facilities available in the hospital are as follows: -

1. Hospital


1. Name ........................................................................
2. Location ...................................................................
3. Govt. /Pvt..................................................................
4. Teaching/Non-teaching.................................................
5. Approached by:



Road: Rail: Air:

Yes Yes Yes

No No No

2. Total bed strength: .....................................................
3. Name of the disciplines in the hospital .............................
4. Annualbudget .............................................................
5. Patient turnover / year .................................................
6. Surgical Team
1. No. ofbeds ................................................................
2. No. of permanent staff members with their designations. .........................................................................
3. No. of temporary staff with their designations ................ .............................................................................
4. No. of operations done per year ............................................................
5. Trained persons available for transplantation
           (Please specify organ for transplantation)
7. Medical Team
1. No. of beds ............................................................
2. No. of permanent staff members with their designations ....................................................
3. No. of temporary staff members with their designations. ..............................................................................
4. Patient turnover per year ............................................................…................
5. No. of potential transplant candidates admitted per year .................................................
8. Anaesthesiology
1. No. of permanent staff members with their designations..............................................................
2. No. of temporary staff members with their designations.................................................................
3. Name and No. of operations performed ..............................
4. Name and No. of equipments available ............................. …
5. Total No. of operation theatres in the hospital ....................
6. No. of emergency operation theatres ................................
7. No. of separate transplant operation theatres .....................
9. I.C.U./H.D.U. Facilities
1. ICU/HDU facilities: Present .............. Not present .............
2. No. of ICU beds ..................
3. Trained
   Nurses ....................
   Technicians ..................
4. Name and number of equipments in ICU ...........................
10. Other supportive Facilities
Data about facilities available in the hospital ......................
11. Laboratory Facilities
1. No. of permanent staff with their designations. ...................
2. No. of temporary staff with their designations. ..................
3. Names of the investigations carried out in the Deptt.........................................................
4. Name and no of equipments available. ..............................
12. Imaging Services
1. No. of permanent staff with their designations ....................
2. No. of temporary staff with their designations ....................
3. Names of the investigations carried out in the Deptt........................................................................
4. Name and no of equipments available................................
13. Haematology services
1. No. of permanent staff with their designations....................
2. No. of temporary staff with their designations.....................
3. Names of the investigations carried out in the Deptt...............................................
4. Name and no of equipments available...............................
14. Blood Bank Facilities
          Yes ................ No .................
15. Dialysis Facilities
          Yes ................ No .................
16. Other Personnel

1.Nephrologist 2.Neurologist 3.Neuro-Surgeon 4.Urologist 5.G.I. Surgeon 6.Paediatrician 7.Physiotherapist 8.Social Worker 9.Immunologists 10.Cardiologist

Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

   The above said information is true to the best of my knowledge and I have no objection to any scrutiny of our facility by authorized personnel. A Bank Draft / Cheque of Rs. 1,000/- is being enclosed.


Head of the Institution

FORM 12

CERTIFICATE OF REGISTRATION

This is to certify that ................... hospital located at ........................ has been inspected by the Appropriate Authority and certificate of registration is granted for performing the organ transplantation of the following organs: -

...............................
...............................
...............................
...............................

This certificate of registration is valid for a period of five years form the date of issue.


Signature ..................... Signature .....................

FORM 13

[Refer sub-rule 8(2)]

OFFICE OF THE APPROPRIATE AUTHORITY

This is with reference to the application, dated ................ form .................. (Name of the hospital) for renewal of certificate of registration for performing organ transplantation, under the Act.

After having considered the facilities and standards of the above said hospital, the Appropriate Authority hereby renews the certificate of registration of the said hospital for the purpose of performing organ transplantation for a period of five years.

Appropriate authority ..................

Place .......................
Date .......................